Background-Streptococcus pneumoniae is the leading cause of community acquired pneumonia; however, only a small proportion of cases can be detected by conventional methods. The ability of the polymerase chain reaction (PCR) test performed on whole blood samples to identify patients with pneumococcal pneumonia was investigated. Methods-One hundred and fourteen consecutive adult patients with community acquired pneumonia were evaluated by a wide battery of diagnostic tests in order to determine the aetiology. Blood samples from these patients and 50 controls were also tested by the nested PCR test to detect selected pneumolysin gene fragments of S pneumoniae. Results-The patients were divided into four groups: (1) 40 patients with pneumococcal pneumonia in 22 of whom (55%) the PCR was positive (eight of 11 with bacteraemia and 14 of 29 without); (2) 30 with pneumonia due to other pathogens in all of whom the PCR was negative; (3) 44 with pneumonia of unknown aetiology in 14 of whom (32%) PCR was positive, and (4) 50 controls in whom the PCR test was positive in two (4%). Thus, the sensitivity of the test was 55% and the specificity 100% (81% if positive PCR tests among undiagnosed patients are considered as false positive results). Conclusion-PCR applied to whole blood samples appears to be a sensitive and very specific diagnostic test for identifying patients with pneumococcal pneumonia with a potential application in clinical practice. (Thorax 2000;55:133-137)

Objectives To evaluate the application in clinical practice, of the acid dissociation in the patients' monitoring with subtherapeutic serum concentrations of infliximab (IFX), adalimumab (ADL) and etanercept (ETN), using an immmunoassay (ELISA) commercialized (Promonitor®, Proteomika S.L.). Methods For 3 years 499 trough samples were analyzed of 218 patients with different rheumatic pathologies treated with IFX (30 patients, 80 samples), ADL (116 patients, 238 samples) and ETN (72 patients, 181 samples). With the standard technology ADA was detected in 27, 16 and 0% of the patients treated with IFX, ADL and ETN respectively, coinciding always with a level of undetectable drug. 76 samples quantified with detectable but subtherapeutic levels at the standard treatment (26 samples of 20 patients with IFX <2 mg/L, 32 samples of 22 patients with ADL <3 mg/L and 18 samples of 15 patients with ETN <2 mg/L), that were analyzed for ADA after submitting them to an acid pre-treatment. The protocol of acidification consisted of the incubation of the serum during 15 minutes with acetic acid 300 mM and later neutralization with Tris 1 M fitting to a final dilution 1/10. Results With the protocol of acid dissociation anti-ADL antibodies were detected in 55% of the patients with subtherapeutic levels of ADL, which were undetectable with the standard assay (17 samples, 12 patients, middle age: 55 years, 67% women, diagnoses: 8 ankylosing spondylitis (BASDAI:4,8±1,5), 3 rheumatoid arthritis and 1 psoriasic arthritis (DAS28: 3,5±0,2). In 7 cases ADA's detection after acidificatiόn was produced already in the first request of monitoring to 6 months of initiated the treatment. In other 3 cases, ADA's positive after dissociation confirmed a previous positive with the standard assay. Initially the treatment was kept with ADL in 5 patients, which ended up by turning out to be positives with the standard technology between 2 and 6 months after the positive with dissociation. Finally, in 12 patients a change of treatment was necessary for lack of clinical response, being chosen by another anti-TNF before ADA's evidence. ADL's maximum concentration in the samples with a positive result was of 1,8 mg/L and the title of detected antibodies ranged between 35 and 282 UA/mL. Anti-IFX not anti-ETN antibodies were not detected after the acidificaciόn of the samples by subtherapeutic concentrations of these two drugs. Conclusions 1) The acid pre-treatment of the samples increases the sensibility of the test of detection of anti-drug antibodies breaking possible drug-antibody complexes. 2)The monitoring of inmunogenicity in patients with subtherapeutic levels of ADL, following a protocol of acid dissociation, has allowed us to detect in a precocious way ADA's presence in these patients contributing to the optimization of the treatment. 3) On the basis of our experience we recommend its application in case of patients with an ADL trough concentration of lower than 2 mg/L following the standard treatment. Disclosure of Interest : None declare...

ObjectivesTo know the musculoskeletal ultrasound (MUS) use and skills among young rheumatologists in Europe, the availability of ultrasound facility in his workplace and the applications of this technique in daily clinical practice.MethodsAll rheumatologist members of EMEUNET (EMerging EULar NETwork), a network of young rheumatologists in Europe, were email solicited to participate in this online survey. The questionnaire consists of 23 questions regarding demographic data, availability of an ultrasound facility in the workplace, MUS clinical use, and specific training in MUS. Simple descriptive statistics were calculated.Results223 rheumatologists of 48 countries responded the survey. 55% were woman, and average age was 33 years (range 25-50). 43% were still rheumatology trainees and 73,5% work in a teaching hospital, most of them in the public health systems (65,5%). Most of the responders had an MUS facility during his fellowship (77,6%) and in his current workplace (82,5%). 47% of respondents perform more than 5 MUS scans in one week, while 30,5% perform less than 5 scans per week and 22,5% usually do not perform any scan in one week. Only 37% admit to have a specific time scheduled in their agenda to perform MUS. This technique was used regularly to confirm/exclude the diagnosis of rheumatoid arthritis (81,6%), soft tissue pathology (67,7%), and spondyloarthritis (52,9%), but only few of the respondents use it to diagnose vasculitis, like temporal arteritis (16,4%). Regarding activity assessment, 76,7% regularly use MUS to monitor rheumatoid arthritis, but only 35% use it to monitor spondyloarthritis. 64,6% use MUS to perform sonographic-guided musculoskeletal interventional procedures. The anatomical regions most frequently explored are listed in table 1, and the most complicated regions to scan are listed in table 2. 64,1% of the respondents thought that their use of MUS in clinical practice was less than desirable, due a lack of training (51,4%) or a lack of time (26%). The vast majority of surveyed (93,3%) had received some MUS training but 67,1% thought that their skills in MUS were not adequate for their needs.Table 1.Anatomical region more frequently exploredWrists/hands131 (58,74%)Shoulders39 (17,49%)Knees38 (17,04%)Hips7 (3,14%)Ankles/feet6 (2,69%)Elbows2 (0,9%)Table 2.Anatomical region more diffucult to scanShoulders78 (34,98%)Ankles/Feet66 (29,59%)Hips48 (21,52%)Wrists/hands19 (8,52%)Elbows10 (4,48%)Knees2 (0,9%)Conclusions1. The availability of ultrasound equipment in rheumatology clinics is high. 2. Almos half of respondents perform more than 5 MUS scans per week, and 37% have a specific time scheduled in their work agendas. 3. Use MUS to confirm the diagnosis and to assess activity of RA was regularly done by most of the surveyed.AcknowledgementsThis study was supported by a grant from Asociaciόn para la Investigaciόn en Reumatología Marina Baixa (AIRE-MB). With the endorsement of EMEUNET (Emerging EULAR NETwork) and with the kind help of EMEUNET working group.Disclosure of InterestNone declared

BackgroundPatients with systemic autoimmune diseases (SAD) have higher incidence of infections. In our Service, until 2014 about 50% of patients did not complete vaccination for pneumococcus or hepatitis B virus (HBV).ObjectivesTo know the characteristics of vaccinated patients and advantages of vaccination by Rheumatology nurse (Nurse-RHEU).MethodsObservational study of patients in follow-up in rheumatology, vaccinated from 2015–2017, by SAD in treatment with biological therapy and/or immunosuppressive, by Nurse-RHEU, following the recommendations from SVR and the Valencian Society of Preventive Medicine and Public Health Consensus Document for the vaccination of patients with SAD, published in 2014. Nurse-RHEU, assumed from 2015 the vaccination of all rheumatology patients with SAD. The vaccines to be administered were: pneumococcal (13 V and/or 23 V) and hepatitis B virus (HBV).Pneumococcal vaccination should be initiated with the conjugate/13 V type and at least 8 weeks later with a dose of polysaccharide/23 V vaccine. A single 23 V booster dose is recommended 5 years after the first dose. Only if patient have received a previous dose of 23 V, it is advisable to administer type 13 V, one year later. For the HBV vaccine, it is necessary previously check the immune status of the subject. If it is not immune, 3 doses will be administered (0–1–6 months).Since 2015, our Section has: refrigerator, electronic access to the Vaccinated Nominal Registry of the Valencian Community (it collects data of the patient, date, type, batch of vaccine administered), specific database (epidemiological data of the patients, future dose programming, access to electronic medical records) and Nurse-RHEU trained. Previously, the nurse details possible side effects, and how to act or contact.ResultsOf the 261 patients vaccinated during 2015 to 2017, 65% were women, with mean age 53.57±15.50 years (10–81 years). The diagnosis was: rheumatoid arthritis: 48%, ankylosing spondylitis: 23%, psoriatic arthritis: 13%, systemic lupus erythematosus: 7%, uveitis: 4%, and others 5%. The reason for vaccination was: initiation treatment with a biological drug (51%), or immunosuppressive (49%). A total of 621 vaccines were administered, which were: 13-valent conjugate antineumotococcal: 259 (42%), 1 st VHB dose: 94 (15%), 2nd VHB dose: 85 (14%), 3rd VHB dose: 72 (12%), pneumococcal 23-valent polysaccharide: 111 (17%). All vaccines were registered in the Vaccinated Nominal Register of the Valencian Community.Conclusions1. Patients with SAD in biological treatment and/or immunosuppressant, vaccinated by Nurse-RHEU, achieve a completeness of all doses of vaccination, close to 100%. 2. In a large part of the patients, vaccination is scheduled at the beginning of the diagnosis of the disease, at the first consultation or immunosuppressive treatment, the same day of the visit to the Rheumatologist, avoiding unnecessary visits to the patient. 3. An adequate electronic registry allows immediate access to information from any point in the Valencian Community, ...